肺动脉漂浮导管-PAC.ppt

肺动脉漂浮导管的应用,Contents,Introduction,PAC Placement,Hemodynamic Monitoring,Controversy on PAC,Parameter integration,Cases Discussion,What is Pulmonary Artery Catheter?,Full name:Swan-Ganz CatheterUsed it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clinical measures,Clinical use of the PAC（Diagnosis）,Differentiation among causes of shock Cardiogenic Hypovolemic Distributive(sepsis)Obstructive(massive pulmonary embolism)Differentiation of pulmonary edema Cardiogenic Noncardiogenic Evaluation of pulmonary hypertensionDiagnosis of left-to-right intracardiac shunt Diagnosis of pericardial tamponade,Clinical use of the PAC（Therapy）,Management of perioperative patient with unstable cardiac status Management of complicated myocardial infarction Management of severe preeclampsia Guide to pharmacologic therapy Vasopressors；Inotropes；VasodilatorsGuide to nonpharmacologic therapy Fluid management；Burns；Renal failure；Sepsis；Heart failure；Decompensated cirrhosis Ventilator management Assessment of best PEEP for DO2,Contents,Introduction,PAC Placement,Hemodynamic Monitoring,Controversy on PAC,Parameter integration,Cases Discussion,Structure of PAC,PAC,首选：右颈内静脉,Comparison among PA catheter insertion sites,PAC insertion,Right internal jugular vein Shortest and straightest path to the heartLeft subclavian Does not require the PAC to pass and course at an acute angle to enter the SVC Femoral veins Distant sites Passing a PAC into the heart can be difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrhage is high,PAC insertion,After inserting the PAC as far as the 20cm mark，the balloon is inflated with air.Inflation should be slow and controlled(1 mL/s)and should not surpass the recommended volume(1.5 mL).Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC.CRX：check the position of the PAC PA diastolic pressure PAWP,PAC on CRX（PA）,Placement of the catheter,Right Atrium,20 cmNormal right atrial presssure is 0-6cmHg.Normal oxygen content 15%（ml/dL)Normal O2 saturation 75%,Waveforms of CVP,EKG-RAP,Right Atrium,Right ventricular waveform,RV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75%,Pulmonary artery waveform,Normal PA pressure,systolic 15-30Normal PA pressure,diastolic 5-13O2 content 15%（ml/dL)O2 saturation 75%,EKG-PAP,Pulmonary artery waveform,PAWP waveform,PAWP waveform,EKG-PAWP,PAWP waveform,ECG-CVP-PAWP,How do u know u r in Zone 3？,Catheter should be below the left atrium on CRXIf there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3If PAD PAWP then you are likely not in Zone 3,Rapid Flush Test（方波试验）,Phlebostatic Axis,PAC并发症、可能原因、预防及处理,PAC并发症、可能原因、预防及处理,Contents,Introduction,PAC Placement,Hemodynamic Monitoring,Controversy on PAC,Parameter integration,Hemodynamic values of normal adults,Hemodynamic Monitoring,CO CI SV SVI,RAP(CVP)PAP PAWP,Cardiac output,Pressure,SvO2,Cardiac Output（CO）,定义：在1min内从心室射 出的血液总量公式：CO=HR x SVCO=48 L/min,Cardiac Output Index（CI）,CI CO/BSA 正常值:2.8 4.2 L/min/m2 CI更能体现患者的个体差异性,每搏量(SV)与 每搏量指数(SVI),SV定义：每次心跳所射出的血液量SV=CO/HR SV正常值：50-110ml/beatSVISV/BSA SVI正常值：30-65ml/m2/beat,What Elevates the Right Atrial Pressure?,RV infarctPulmonary hypertensionPulmonary stenosisLeft to right shuntTricuspid valvular diseaseLeft heart failure,Prominent RA pulsations,Prominent a wave:Tricuspid stenosisCannon a wave:AV dissociation Ventricular tachycardiaProminent v wave:Tricuspid regurgitation or VSD,What Increases RV Pressures?,RV failurePulmonary hypertensionPulmonary stenosisPulmonary EmbolismCardiomyopathyCardiac tamponadeCardiac constriction,What Elevates PA pressure?,Volume Overload(backflow)Primary lung diseasePrimary pulmonary hypertensionPulmonary EmbolismLeft to right shuntMitral Valve Disease,用压力推测心室舒张末期容量的前提,导管位置 无二尖瓣 心室顺应性 正确 疾病 正常 PAWP LAP LVEDP LVEDV Preload,PAWP and LVEDP may be discordant,Conditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus Conditions in which PAWP25 mmHg)LVEDP,Systemic and pulmonary vascular resistance,80*(MPAP-LAP)/肺血流量,80*(MAP-RAP)/CO,R=U/I,PVR,SVR,欧姆定理,Systemic Vascular Resistance,Causes of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosity,Causes of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tone,Pulmonary Vascular Resistance,Causes of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defects,Causes of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）,SvO2,Contents,Introduction,PAC Placement,Hemodynamic Monitoring,Controversy on PAC,Parameter integration,Cases Discussion,PAC为何不能改善预后？,问题何在,1,2,3,4,5,不恰当的适应症,PAC相关的并发症,数据的可靠性,不恰当的治疗,数据解读的准确性,We still need PAC？,到底是谁的问题？,Iberti et al(JAMA 1990)美国和加拿大13家医院 496MD 47的受试者对PAC不能作出正确回答Gnaegi A et al(CCM1997)134个ICU的535 MD 68的医生所具有的知识不能满足PAC使用Squara P et al(Chest 2002)仅有38的医生按照给出的PAC数据选择了正确的治 疗方案，但仍有多达35的医师选择了错误的治疗方案,临床评价 VS 血流动力学,103例PAC医生在置管前对血流动力学指标的范围及治疗方案进行预测预测准确性：PAWP 30%；CO SVR RAP 50%留置PAC后：治疗计划需要重新修正 58%应用未预计到的治疗 30%结论：1 单纯根据临床评价难以准确预测血流动力学指标 2 PAC监测将改变治疗策略,Crit Care Med.1984 Jul;12(7):549-53.,Benefit or Harm？,能否替代PAC？,Contents,Introduction,PAC Placement,Hemodynamic Monitoring,Controversy on PAC,Parameter integration,Cases Discussion,PAC要回答的四个问题,PAC参数整合：前负荷,CVP（RAP）/PAWP Any given level of filling pressure:not reliable！Static markers of cardiac preload fail to predict volume responsivenessFluid challnge CVP 2-5 rule PAWP 3-7 rule CO/CI/SV 10%,PAC参数整合：后负荷,左室射血的阻抗及外 周阻力 SAP MAP SVR,后负荷,右室射血的阻抗及外 周阻力 PAP MPAP PVR,PAC参数整合：心脏收缩力,CO并不是心脏射血功能的可靠指标每搏输出量（SV）/每搏指数（SVI）SV/SVI增加的原因：代偿；SVR下降SV/SVI降低的原因：前负荷下降：出血 心肌收缩力下降：心功能不全（EF%）后负荷增加：SVR增加,PAC参数整合：氧代谢,Oxygen Delivery:What are the components?,Oxygen DeliveryDO2,Cardiac Output,Heart Rate,Stroke Volume,CaO2,PaO2,SaO2,Hb,Preload,Afterload,Contractility,CVPPCWP,PVRSVR,EF%,PAC目标指导性治疗,CI 4.5L/min/m2,DO2600mL/min/m2,VO2170mL/min/m2,Shoemaker WC et al.Chest.1988 Dec;94(6):1176-86.,PAC目标指导性治疗,Crit Care Med.2002 Aug;30(8):1686-92,CI 4.5L/min/m2DO2600mL/min/m2VO2170mL/min/m2PAWP18mmHg,基于PAC参数的常见危重病的诊断,基于PAC参数的急性右心衰诊断,基于PAC参数的急性左心衰诊断,基于PAC参数的感染性休克诊断,基于PAC参数的失血性休克诊断,基于PAC参数的急性肺栓塞诊断,PAC病例,Case 1 Fluid challenge,Case 2 Fluid challenge,Case 2 Diuretic,Case 2 Diuretic,Case3 Vasodilator Therapy,71/MAnterior wall myocardial infarctionPE:BP 132/82 HR 116 R 28.+2 edema of the lower extremitiesLab:Na 132 Scr 88ECG:anterior lead S-T elevations CRX:cardiomegaly with pulmonary edemaThe patient was admitted to the ICU and PAC was placed for optimization of cardiac statusNitroprusside was titrated,Case3 Vasodilator Therapy,Case 4 Cardiac tonic,Case 4 Cardiac tonic,Case 5 Septic Shock,52/FESWL;urinary tract infectionsBP 100/45 HR 120 RR 40 T 39WBC 13100,Na 138,K 5.1,Glu 16,scr 180 CRX:normal；EKG:sinus tachycardia.Urine Cultures；started on mezlocillin and gentamicin.On day2，SBP dropped to 70 mmHg；ABG（Fi02 60%）:pH 7.38,PaO2 42,PaCO2 49 Sa02 75%.CRX showed diffuse bilateral infiltrates.Transferred to the ICU：volume resuscitated,intubated and started on intravenous inotropes and vasopressors.PAC was inserted.The patient remained oliguric,uremic and therefore hemodialysis was started.MV was maintained with high FiO2 and PEEP,Case 5 Septic Shock,Thank You!,